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PW5 After Hours Work Permit Application Orient and affix BIS job number label here Must be typewritten All information must be completed for review of this request. Incomplete submissions will be denied without review. The deadline to submit weekend variance requests is Tuesday at 3 00PM and variances will not be granted for any day earlier than Saturday of the same week. 1 Filing Status Information Required for all applications. Check applicable box for application type. Work Permit No* BIS Job Electrical Application Variance Type Initial Renewal 2 Location Information Required for all applications. House No s Street Name Borough Block Lot BIN CB No* Work on Floor s Apt/Condo No s 3 Contractor Required for all applications. Business Fax and Email are optional* Last Name Middle Initial First Name Business Name Business Telephone Business Address City Business Fax / Email State License Number Zip License Type Mobile Telephone GC Electrician MP FSC Other 4 Subcontractor If a subcontractor is involved in this work their information must be provided* Business Fax and Email are optional* 5 Variance Information Required for all applications. Is a residence within 200 feet of the site Yes Days of Week Date s Requested No Total Number of Days Requested Hours Monday to Tuesday Description of Work Specify weekday vs. weekend work Weekday Wednesday Thursday Friday Saturday Sunday Weekend Reason for Variance 6 Statements and Signature Required for all applications. Internal Use Only This permit must be posted visible to the public* Falsification of any statement is a misdemeanor and is punishable by a fine or imprisonment or both. It is unlawful to give to a city employee or for a city employee to accept any benefit monetary or otherwise either as a gratuity for properly performing the job or in exchange for special consideration* Violation is punishable by imprisonment or fine or both. I understand that if I am found after hearing to have knowingly or negligently made a false statement or to have knowingly or negligently falsified or allowed to be falsified any certificate form signed statement application report or certification of the correction of a violation required under the provisions of this code or of a rule of any agency I may be barred from filing further applications or documents with the Department. I hereby certify that I have developed a noise mitigation plan for the site in accordance with Administrative Code 24-219 through 24-224 and that such plan is in compliance with the Department of Environmental Protection s noise mitigation rules. Approved Denied Limited Approval Indicate days-of-week authorized for electronic renewal Limited to Contractor Name print Borough Commissioner Signature Signature Date Filing Fee Permit Fee 12/10. Incomplete submissions will be denied without review. The deadline to submit weekend variance requests is Tuesday at 3 00PM and variances will not be granted for any day earlier than Saturday of the same week. 1 Filing Status Information Required for all applications. Check applicable box for application type.

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